Patient History Information Form

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Overlake Obstetricians and Gynecologists, PC
Patient History Information
Last Name: ________________________________________ First Name: _________________________________________
Birth Date: _________________________________________ Today’s Date: ________________________________________
Reason(s) for Visit: ______________________________________________________________________________________
CURRENT Health/Medical Problems:
Please describe any current medical problems and the care provider that you are seeing to treat this problem:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Past Medical History:
Have you ever had any of the following conditions? If so, please circle AND write details at the bottom of the list:
Bladder Problems
High Blood Pressure
Bleeding Disorders
Migraine Headaches
Blood Transfusions
Osteoporosis
Cancer
Psychiatric Problems
Deep Vein Thrombosis
Pulmonary Embolism
Depression/ Anxiety
Respiratory Problems/ Asthma
Diabetes
Seizure Disorder or Other Neurologic Problem
Heart Disease or Murmur
Stomach or Bowel Problems
Hepatitis
Thyroid
OTHER:
Past Medical History Details:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Health Care Maintenance Details:
Date of last Pap
Date of last Mammogram
Date of last DEXA/Bone Scan
Date of last Colonoscopy
Date of last Annual Blood Test
(eg. Cholesterol, Complete Blood Count, etc.)
Past Surgical History:
Type of Surgery:
Date:
Doctor/Location:
__________________________________________
______________
______________________________________
__________________________________________
______________
______________________________________
__________________________________________
______________
______________________________________
__________________________________________
______________
______________________________________
Current Medications and Supplements:
Please list all current medications and supplements, both prescription and over-the-counter, including dose and frequency if possible.
(OVER)
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